Management of Urethral Strictures After Hypospadias Repair.

Strictures of the neourethra after hypospadias surgery are more common after skin flap repairs than urethral plate or neo-plate tubularizations. The diagnosis of stricture after hypospadias repair is suspected based on symptoms of stranguria, urinary retention, and/or urinary tract infection. It is confirmed by urethroscopy during anticipated repair, without preoperative urethrography. The most common repairs for neourethra stricture after hypospadias surgery are single-stage dorsal inlay graft and 2-stage labial mucosa replacement urethroplasty.

Patient Reported Outcomes in Preoperative and Postoperative Patients with Hypospadias.

PURPOSE: Current outcome tools for hypospadias have limited focus on the caregiver or patient perspective of important patient centered outcomes. In this study we collaborated with patients, caregivers, and lay and medical experts to develop and pilot a patient reported outcome measure for hypospadias. MATERIALS AND METHODS: We developed a patient reported outcome measure based on systematic review of the literature and focus group input. The patient reported outcome measure was piloted in caregivers for boys younger than 8 years and in patients older than 8 years who presented for urology consultation before meeting with the surgeon. Patients were classified with uncorrected hypospadias, successful repair or failed repair based on the presence or absence of complications (fistula, diverticulum, meatal stenosis/stricture, greater than 30-degree recurrent curvature, glans dehiscence and/or skin reoperation). RESULTS: A patient reported outcome measure was developed and administered to 347 patients and/or caregivers-proxies, including 105 uncorrected cases, 162 successful repair cases and 80 failed cases. Satisfaction with appearance was highest in those with successful hypospadias repair compared to failed repair and uncorrected hypospadias (93% vs 77% and 67%, respectively). Voiding symptoms such as spraying or a deviated stream were highest in failed and uncorrected cases (39% and 37%, respectively). Overall dissatisfaction with voiding was highest for uncorrected hypospadias and failed repair compared to successful cases (54% and 47%, respectively, vs 15%). CONCLUSIONS: The evaluation of patient and caregiver-proxy reported outcomes in preoperative and postoperative patients with hypospadias allows for the quantification of benefits derived from hypospadias repair and may ultimately represent the gold standard outcome measure for hypospadias. This pilot study identified preliminary patient centered themes and demonstrated the feasibility of administering hypospadias patient reported outcome measures in clinical practice.

Objective use of testosterone reveals androgen insensitivity in patients with proximal hypospadias.

OBJECTIVE: We report preoperative testosterone stimulation based on glans width measurements in patients with midshaft and proximal hypospadias, revealing androgen resistance in those with proximal hypospadias. METHODS: Patients had maximum glans width measured preoperatively. Those <14 mm initially received 2 mg/kg testosterone cypionate intramuscularly for two to three doses, with the aim of increasing glans width ≥ 15 mm. Not all patients achieved targeted growth, and some were subsequently treated with escalating doses of testosterone. RESULTS: 5/15 midshaft patients had two to three doses of 2 mg/kg testosterone, with all increasing glans width to ≥ 15 mm. 29/47 proximal patients had testosterone, with 13 (57%) not reaching desired glans width. Six of these and another six patients had escalating doses from 4 to 32 mg/kg testosterone, with 11 then achieving targeted glans width. Relative androgen resistance was found in 19/29 (66%) proximal cases, including all treated patients with perineal hypospadias. CONCLUSIONS: 39/62 (63%) patients met objective criteria for preoperative testosterone stimulation based on glans width <14 mm, which is less than the average normal newborn glans diameter. Evidence of relative androgen resistance was found in 19 (49%), all with proximal hypospadias.

Glans penis width in patients with hypospadias compared to healthy controls.

PURPOSE: There are no reports of systematically-measured penile dimensions in boys with varying extents of hypospadias. To determine reference values, we prospectively measured maximum glans width in patients undergoing distal and proximal hypospadias repair as well as newborns undergoing elective circumcision. METHODS: The maximum glans diameter was measured in consecutive boys aged 0-24 months presenting for newborn circumcision (controls), or repair of distal (distal shaft or glanular) and proximal (proximal shaft to perineal) hypospadias. Patients with proximal hypospadias and glans diameter <14 mm received intramuscular testosterone 2 mg/kg injection once monthly for 2-3 treatments, with measurements recorded prior to the first injection, and again intra-operatively 3-4 weeks after the final injection. RESULTS: Data were obtained in 240 controls, 188 boys with distal hypospadias, and 39 boys with proximal hypospadias. Median ages were 1, 9 and 9 months, respectively. Males undergoing newborn circumcision were younger than both cohorts of hypospadias patients (p < 0.0001), but no difference in age was noted in those with distal and proximal hypospadias (p = 0.194). Average maximum glans diameters were significantly different: 14.3, 14.8, and 12.9 mm, respectively, for controls, distal and proximal hypospadias (p < 0.0001). Despite mean older age, 46 (24.5%) boys with distal hypospadias and 24 (61.5%) with proximal hypospadias had small glans diameter <14 mm. Increasing age was not correlated with increasing glans size in patients with distal or proximal hypospadias (r = -0.136, p = 0.062 and r = -0.089, p = 0.580) at 3-24 months of age. CONCLUSION: Some boys with distal and the majority of those with proximal hypospadias have a glans width less than that of the average normal newborn. Glans size does not correlate with age in patients with hypospadias between 3 and 24 months old, supporting the decision to operate as early as 3 months in some centers.

Urethral strictures following urethral plate and proximal urethral elevation during proximal TIP hypospadias repair.

INTRODUCTION: We previously described urethral plate (UP) dissection and urethral mobilization from the corpora cavernosa to achieve or facilitate straightening ventral curvature while preserving the UP for TIP in boys with proximal hypospadias. The original patients had similar complications to those undergoing proximal TIP without UP elevation. Subsequently an increased occurrence of neourethra strictures in those with UP elevation and urethral mobilization was recognized, and is now reported. MATERIALS: Information on consecutive patients with proximal TIP repair with and without UP elevation and urethral mobilization by a single surgeon was reviewed in a database with pre-determined data points entered on the day of service. RESULTS: There were 76 proximal TIP patients with follow up, 29 with and 47 without UP elevation and urethral mobilization, with strictures developing in 5 (17%) and 0, respectively, p = 0.01. All strictures were symptomatic (UTI, urinary retention), 0.1-1.0 cm long, and diagnosed at ≤1.5 years after surgery. CONCLUSIONS: UP elevation and urethral mobilization with TIP resulted in focal devascularization of the neourethra with symptomatic stricture development. Although most patients with these straightening maneuvers did not have stricture, we no longer recommend UP elevation and urethral mobilization with proximal TIP repair.

Prevalence and risk factors for renal scars in children with febrile UTI and/or VUR: a cross-sectional observational study of 565 consecutive patients.

PURPOSE: To determine prevalence and risk factors for renal scar in children referred for urologic assessment of febrile UTI and/or VUR. METHODS: Pre-determined risk factors for renal scar were prospectively recorded in consecutive patients referred for UTI/VUR. Age, gender, VUR grade, and reported number of febrile and non-febrile UTIs were analyzed with logistic regression to determine risk for focal cortical defects on non-acute DMSA. RESULTS: Of 565 consecutive children, 24 (4%) had congenital renal dysplasia and 84 (15.5%) had focal defect(s). VUR, especially grades IV-V, recurrent febrile UTI, and older age increased risk. For any age child with the same number of UTIs, VUR increased odds of renal defect 5.4-fold (OR = 5.4, 95% CI = 2.7-10.6, AUC = 0.759). CONCLUSIONS: Focal DMSA defects were present in 15.5% of 565 consecutive children referred for febrile UTI and/or VUR; 4% had presumed congenital reflux nephropathy without cortical defect. All VUR grades increased risk for these defects, as did recurrent febrile UTIs and older age. However, 43% with grades IV-V VUR and 76% with recurrent UTI had normal DMSA.

Vesicoureteral reflux: current trends in diagnosis, screening, and treatment.

CONTEXT: Vesicoureteral reflux (VUR) is present in approximately 1% of children in North America and Europe and is associated with an increased risk of pyelonephritis and renal scarring. Despite its prevalence and potential morbidity, however, many aspects of VUR management are controversial. OBJECTIVE: Review the evidence surrounding current controversies in VUR diagnosis, screening, and treatment. EVIDENCE ACQUISITION: A systematic review was performed of Medline, Embase, Prospero, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, clinicaltrials.gov, and the most recent guidelines of relevant medical specialty organizations. EVIDENCE SYNTHESIS: We objectively assessed and summarized the published data, focusing on recent areas of controversy relating to VUR screening, diagnosis, and treatment. CONCLUSIONS: The evidence base for many current management patterns in VUR is limited. Areas that could significantly benefit from additional future research include improved identification of children who are at risk for VUR-related renal morbidity, improved stratification tools for determining which children would benefit most from which VUR treatment option, and improved reporting of long-term outcomes of VUR treatments.

Parental preferences in the management of vesicoureteral reflux.

PURPOSE: Considering that there are few absolute indications for the timing and type of surgical correction of vesicoureteral reflux, we objectively measured parental choice in how the child's vesicoureteral reflux should be managed. MATERIALS AND METHODS: We prospectively identified patients 0 to 18 years old with any grade of newly diagnosed vesicoureteral reflux. All races and genders were included, and non-English speakers were excluded from analysis. Parents were shown a video presented by a professional actor that objectively described vesicoureteral reflux and the 3 treatment modalities of antibiotic prophylaxis, open ureteral reimplantation and endoscopic treatment. Then they completed a questionnaire regarding their preference for initial management, and at hypothetical followup points of 18, 36 and 54 months. Consultation followed with the pediatric urologist who was blinded to the questionnaire results. RESULTS: A total of 86 girls and 15 boys (150 refluxing units) were enrolled in the study. Mean patient age was 2.6 years old. Preferences for initial treatment were antibiotic prophylaxis in 36, endoscopic surgery in 26, open surgery in 11, unsure in 26 and no response in 2. Among those initially selecting antibiotic prophylaxis, after 18 months the preference was for endoscopic treatment, but after 36 and 54 months preferences trended toward open surgery. After consultation with the pediatric urologist 68 parents chose antibiotic prophylaxis. CONCLUSIONS: Our data show that antibiotic prophylaxis is preferred as the initial therapy for vesicoureteral reflux by 35.6% of parents. However, given persistent vesicoureteral reflux, preferences shifted toward surgery. With time the preference for open surgery increased and the preference for endoscopic surgery decreased.

Febrile urinary tract infection, vesicoureteral reflux, and renal scarring: current controversies in approach to evaluation.

The ideal approach to the radiological evaluation of children with urinary tract infection (UTI) is in a state of confusion. The conventional bottom-up approach, with its focus on the detection of upper and lower urinary tract abnormalities, including vesicoureteral reflux, has been challenged by the top-down approach, which focuses on confirming the diagnosis of acute pyelonephritis before more invasive imaging is considered. Controversies abound regarding which approach may best assess the ultimate risk for reflux-related renal scarring. Evolving practices motivated by the emerging evidence, the desire to minimize unnecessary interventions, as well as improve compliance with recommended testing, have added to the current controversies. Recent guideline updates and ongoing clinical trials hopefully will help in addressing some of these concerns.